Temporary Additional Support Application Form S26

1 Page 1 S26 FEB 2021 Tell us about yourselfWrite your Client number here. It can be found on your Community Services numberTell us your detailsWhat is your full name?First and middle namesSurname or family nameWhat date were you born?DayMonthYearHOW TO ANSWER Q3:If you live in a rural area, flat/house number could include your RAPID number, fire number, emergency services TO ANSWER Q4:Mailing address can include a PO Box, rural delivery details, or C/O do you live?Flat/House numberStreet nameSuburbTown/CityIs your mailing address different from where you live?NoYe sTell us your mailing addressHOW TO ANSWER Q5:Please only give us contact details you d like us to else can we contact you?

2 Tick the best way for us to first contact youHome phone( )Mobile phone( )Other phone( ) Do you live alone?NoPlease write below the names of the others you live withYe sFirst nameSurname or family nameRelationship to you123456 Temporary Additional Support helps with essential costs for a short time when you ve tried everything you can think of, and still cannot pay for Additional Supportapplication form Page 2S26 FEB 2021 Tell us about your income and assetsTell us about income in the last 52 weeks?ATTACHMENT FOR Q7:Bring a copy of your business FOR Q7:In this Application form , partner means the person you re married to or in a civil union or relationship with, not a business you or your partner get income from any of the following sources in the last 52 weeks?

3 Wages or salaryNoYe sTermination payNoYe sRedundancy payNoYe sAccident compensation (eg ACC)NoYe sIncome insurance (replacement/protection)NoYe sJointly with partnerFarm or business incomeNoYe sJointly with partnerPayments from self employment or contract workNoYe sJointly with partnerInterest from savings, investments, or bondsNoYe sJointly with partnerDividends from shares, unit trusts, or managed fundsNoYe sJointly with partnerIncome from rentsNoYe sJointly with partnerPayments from boarders or flatmatesNoYe sJointly with partnerChild Support paymentsNoYe sOther income for a childNoYe sMaintenance paymentsNoYe sPayments from a former partnerNoYe sStudent Allowance, scholarship, or Student Loan living cost paymentsNoYe sOverseas pension.

4 Benefit or allowance paymentsNoYe sOther superannuation or retirement scheme income (government or private)NoYe sIncome from an estate, if you ve inherited moneyNoYe sJointly with partnerIncome from trustsNoYe sJointly with partnerOtherNoYe sJointly with partnerATTACHMENT FOR Q8:You need to show us proof of income you ve received in the last 52 weeks and details of your income for the last 26 you answer Yes or Jointly with partner to any of the sources of income listed in question 7?NoYe sTell us the total before-tax amounts, for the last 52 weeksPayment made to?Where did the income come from?Yo uYour partnerJointly with partner$$$$$$$$$$$$$$$78 Page 3S26 FEB 2021 Tell us about any Working for Families tax credits you getDo you or your partner get any Working for Families tax credits from Inland Revenue?

5 No tax creditFamily tax creditMinimum family tax creditParental tax creditIn-work tax creditBest Start tax creditPlease write the details of any tax credits belowType of tax creditYo uYour partnerHow often? (For example, weekly, fortnightly)$$$$$$Tell us about your assetsATTACHMENT FOR Q10:You may be asked to provide proof of your assets and their you or your partner have any of the following cash assets?Money in bank or other savingsNoYe sBonds, shares, debentures or stocks NoYe sMoney lent to other people or organisationsNoYe sOther cash assets NoYe sIf you answered yes to any of the assets listed above, please write the details of assetYo uYour partnerJointly owned$$$$$$$$$$$$HOW TO ANSWER Q12:Examples of property you don t live in include, land, holiday homes, bach/crib, investment you or your partner have any of the following non-cash assets?

6 Property you don t live inNoYe sBoat, caravan or motorhomeNoYe sOtherNoYe sATTACHMENT FOR Q13:You may be asked to provide proof of these you answered yes to any of the non-cash assets listed above, please write the details of assetHow much is it worth?How much do you owe on it?$$$$$$910111213 Page 4S26 FEB 2021 Are you involved with a trust?ATTACHMENT FOR Q11:You ll need to show us trust documents, such as the trust deed, deed of debt, gift statements, acc you or your partner involved in a trust, or have you ever been involved in a trust? Involved means one or more of the following: you ve set up a trust, usually by making a gift of assets or property you ve transferred assets to a trust you make decisions about managing a trust you benefit from a trust, for example, by receiving income such as trust sPlease write the name of the trustName of trustTell us about your costsTell us what essential work-related costs you need to pay to keep workingINFORMATION FOR Q16:These are the only work-related essential costs we may be able to help you FOR Q16:You ll need to show proof of these you or your partner working?

7 NoGo to question 17Ye sDo you or your partner have any essential costs that you have to pay to keep working?NoYe sPlease write the details belowType of costHow much?How often?(For example, weekly, fortnightly)Running costs for a vehicle you use to get to and from work$Repayment costs for a vehicle you use to get to and from work$Public transport to and from work$Telephone, if it is a condition of your work$Childcare$141516 Page 5S26 FEB 2021 Tell us how much it costs you for the place where you and your family liveINFORMATION FOR Q18:By rent we mean the amount you pay is for your accommodation only and doesn t include other costs such as food or you getting, or are you applying for, an accommodation supplement ?

8 NoYe sGo to question 31Do you pay rent?NoGo to question 24Ye sDo you pay rent to K inga Ora?NoYe sWhat is the total amount of rent paid each week for your home?$ATTACHMENT FOR Q21:You ll need to show proof of what you pay for FOR Q22:You ll need to show proof of what you pay for water much of this total amount do you pay for you and your family?$Do you pay water rates separately from your rent?NoYe sTell us how much you pay$How oftenWhat is the name, address and telephone number of the person or organisation you pay rent to?Go to question 31 INFORMATION FOR Q24:By board we mean the amount you pay for your accommodation where it includes food costs and may also include other costs like FOR Q25:You ll need to show proof of what you pay for you pay board?

9 NoGo to question 27Ye sList what costs your board includesWhat is the total amount of board you pay for you and your family?$What is the name, address and telephone number of the person or organisation you pay board to?Go to question 3117181920212223242526 Page 6S26 FEB 2021Do you own the home you live in?NoGo to question 31Ye sHOW TO ANSWER Q28:Only include mortgages you used to buy or alter your home. Include both interest and any other mortgages such as a second mortgage or revolving t include contents FOR Q28:You ll need to show proof of your home ownership are your home ownership costs?Who do you pay?How much do you pay?How often do you make the payment (such as weekly, monthly or yearly)?

10 First mortgage$Other mortgage$House insurance$Mortgage insurance$Rates$Ground lease$Water rates$Body corporate fees$ATTACHMENT FOR Q29:Bring receipts for any repair and maintenance you have to pay for repairs and maintenance to your home in the last 12 months?NoYe sPlease write the total amount$Have you received a rates rebate in the last 52 weeks?NoYe sAmount$Rating year 1 July20to 30 June20 Tell us about other essential costsINFORMATION FOR Q31:Essential regular costs can include: hire purchase vehicle repayments costs relating to a health condition or disability lease or hire of an essential household item such as fridge, washing machine, FOR Q31:You ll need to show proof of these you or your family have any regular essential costs?